Dean Ford

Chief Executive Officer 
Trust Head Office 
West Wing 
CEME Centre 
Rainham 
Essex 
RM13 8GQ 

        28th January 2025 

PRIVATE  & CONFIDENTIAL  

Ms Nadia Persaud 
HM Coroner 
East London Coroners Service 
124 Queens Road 
Walthamstow 
London 
E17 8QP 

By email only to:  

Your ref:  
Trust ref: 

Dear Madam 

Re: Inquest touching upon the death of Dean Ford 

I refer to your Regulation 28 report, dated 04 December 2024, following the recent Inquest into 
Mr Ford’s untimely death.  I should first like to extend my sincere condolences to Dean Ford’s 
family.  This must have been an extremely difficult time and I hope that my response provides 
them,  and  you,  with  assurances  that  North  East  London  Foundation  Trust  (NELFT)  is  taking 
action to address the issues set out in your report. 

NELFT acknowledges your concerns and wishes to advise that before and since the sad passing 
of Mr Ford, NELFT has implemented a number of changes.  These include the following: 

1. 

Despite clear guidance from NICE in September 2022 relating to the need for 
a holistic formulation of risk to self, two NELFT teams involved in Mr Ford’s 
crisis care failed to carry out a holistic formulation of the risk he posed to 
himself. 

Risk assessment and formulation remain, of course, key to the work of teams 
across the Trust.  We have a number of processes in place to support practice in 
this area, including supervision, audit and the cascade of guidance to staff 
(supported by trust wide learning lessons events).  Multi-disciplinary working 
within teams is also an important part of practice across the Trust, that aims to 
support safe and effective working within our teams.    

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                     
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 To implement the significant developments in practice outlined in NICE 
guidance, we established a formal steering group in August 2023 after a period 
of national scoping and a review of the available literature.  We made contact 
with Oxford NHS Trust and Kent and Medway NHS and Social Care Partnership 
Trust (KMPT), who we understand were some of the very few NHS trusts to 
have begun full implementation of this guidance at this point in time. 

We have undertaken a very thorough review of all policies, procedures and 
associated training and worked closely with our experts by experience.  We 
launched our Risk Formulation training in September 2024 and have been 
delivering a day-long face-to-face training.  The training utilises videos we made 
of experts by experience and carers talking about their experience of risk and 
suicide.  We have now trained some 80% of our acute and rehabilitation 
colleagues, and moved to Borough based training in January 2025 and have 
started training colleagues in Barking and Dagenham.   

This is a significant change to how NELFT staff conceptualise risk as they move 
from Risk Stratification (Low, Medium, High – Green, Amber, Red) to Risk 
Formulation.  The aim of this work is to support NELFT staff to change the way 
that they perceive and react to risk to incorporate a more holistic and 
individualised approach, and how risk is fluid and not static. This will be a 
significant change in the working culture, and the structure that has been 
established to support this work is intended to support the effective transition to 
these arrangements (a process that brings risk in its own right).  Once 
established, this training will be part of new starters induction programme 
(approximately 60 staff per month) so that risk formulation is embedded at the 
beginning of the staff NELFT journey. 

2. 

A clinical lead for the mental health and wellbeing team within NELFT, 
gave evidence at the inquest in December 2024 that Mr Ford’s risk was 
deemed to be low because “the main factor around risk is that he denied 
any risk to self and denied any suicidal thoughts”.  This simplistic 
assessment of risk is not compliant with the NICE guidelines.  It is of 
concern that a senior member - clinical lead - within the mental health and 
wellbeing team is not applying the correct risk formulation.  

We have addressed this specific feedback with the member of staff involved, 
but, more broadly, we do have processes in place to support effective risk 
assessment within teams.  For example, in the Mental Health Direct service that 
was involved in Mr Ford’s care a monthly sample audit is place that includes 
audits of the risk assessment of calls to MHD clinicians, and the follow up action 
to help address any risks identified.  This includes one third of all calls every 
month.  The staff involved in the work of this realm are, of course, also part of 
the risk formulation training that has taken place. 

Within this service specifically, we have also changed the triage tool that is in 
use and are currently rolling out the nationally recognized Mental Health Triage 
Tool which supports the appropriate prioritization and responses for all mental 
health crisis calls.  We will continue to support the embedding of the tool, by 
monthly monitoring of call outcomes, meeting monthly with local services and 
stakeholders for feedback, as well as engaging carers and service users for 
feedback, which is monitored centrally by the patient experience team in NELFT. 

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 From January 2025, the service will also have additional staffing in place to 
enable the service to be more responsive to calls, thereby improving the 
capacity of the service to monitor and respond to call activity. 

Within the Mental Health and Wellbeing Teams (MHWTs) there are multi-
disciplinary team processes that support effective working.  All new referrals are 
discussed in a daily morning MDT meeting in the Mental Health and Wellbeing 
Teams (MHWTs), and the consultant is now present in the decision-making 
process. If the decision is made to gather more information, staff allocated to the 
duty team on the day will phone the patient, arrange a face-to-face appointment 
or conduct a home visit, and these are all dependent on the discussion that 
takes place in the morning meeting.  There is another daily meeting in the 
evening to discuss the outcomes of all the assessments that take place during 
the day and again the consultant is present in the meeting. 

3. 

The Trust carries out risk assessment audits for clients who are accepted 
into the mental health and wellbeing team. There are no audits into the risk 
assessments for those persons who are referred to the team, but not 
accepted by the team. As these patients have no safety net of ongoing 
mental healthcare, it is of concern that the quality of risk assessments for 
these patients is not audited. 

In the directorate, all new referrals are discussed in a daily morning MDT meeting 
in the MHWTs, and the consultant is now present in the decision-making process. 
If the decision is made to gather more information, staff allocated to the duty team 
on  the  day  phone  the  patient,  arrange  a  face-to-face  appointment  or conduct  a 
home visit, and these are all dependent on the discussion that takes place in the 
morning  meeting.  There  is  another  daily  meeting  in  the  evening  to  discuss  the 
outcomes  of  all  the  assessments  that  take  place  during  the  day  and  again  the 
consultant  is  present  in  the  meeting.  This  along  with  risk  formulation  training, 
combine  to  improve  decision-making.  Patients  not  needing  secondary  care  are 
sign-posted to other services and an outcome letter is sent to the referrer.   

For those patients who are not accepted, the current process is for patients to be 
contacted  either  by  phone,  face-to-face  or  at  a  home  visit  to  conduct  an 
assessment, so as to ascertain whether secondary care is required.  

If I can be of any further assistance or if you would like a further update on the progress made to 
address your concerns, I would be happy to provide a further update. 

Yours sincerely  

Chief Executive Officer 

www.nelft.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 www.nelft.nhs.uk